|
SPLINT FINGER LMB SPRING SZ A #7041-02
|
Facility
|
IP
|
$406.00
|
|
| Hospital Charge Code |
2969713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.94 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$243.60
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
SPLINT FINGER LMB SPRING SZ A #7041-02
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
2969713
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$1,624.00 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$113.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.20
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.50
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$263.90
|
| Rate for Payer: Quartz Medicare Advantage |
$243.60
|
| Rate for Payer: The Alliance Commercial |
$1,624.00
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
SPLINT FINGER LMB SPRING SZ B #7041-03
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
2969626
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$1,624.00 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$113.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.20
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.50
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$263.90
|
| Rate for Payer: Quartz Medicare Advantage |
$243.60
|
| Rate for Payer: The Alliance Commercial |
$1,624.00
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
SPLINT FINGER LMB SPRING SZ B #7041-03
|
Facility
|
IP
|
$406.00
|
|
| Hospital Charge Code |
2969626
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.94 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$243.60
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
SPLINT FINGER LMB SPRING SZ C #7041-04
|
Facility
|
OP
|
$406.00
|
|
| Hospital Charge Code |
2971086
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$1,624.00 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$113.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.20
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.50
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$263.90
|
| Rate for Payer: Quartz Medicare Advantage |
$243.60
|
| Rate for Payer: The Alliance Commercial |
$1,624.00
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
SPLINT FINGER LMB SPRING SZ C #7041-04
|
Facility
|
IP
|
$406.00
|
|
| Hospital Charge Code |
2971086
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.94 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$243.60
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
SPLINT FINGER STAX 5.5 9121-07
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2974195
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
SPLINT FINGER STAX 5.5 9121-07
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2974195
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
SPLINT FINGER STAX #7 9121-08
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
2974196
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.50
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$42.00
|
| Rate for Payer: The Alliance Commercial |
$280.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
SPLINT FINGER STAX #7 9121-08
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
2974196
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
SPLINT FINGER STAX SZ1 9121-01
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974197
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ1 9121-01
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974197
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ2 9121-02
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974198
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ2 9121-02
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974198
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ3 9121-03
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974200
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ3 9121-03
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974200
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ4 9121-04
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ4 9121-04
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ5 9121-05
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974201
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ5 9121-05
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974201
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ6 9121-06
|
Facility
|
IP
|
$44.00
|
|
| Hospital Charge Code |
2974202
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$40.48 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$26.40
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FINGER STAX SZ6 9121-06
|
Facility
|
OP
|
$44.00
|
|
| Hospital Charge Code |
2974202
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.84
|
| Rate for Payer: Aetna Managed Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.32
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$40.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.62
|
| Rate for Payer: Health EOS Commercial |
$39.16
|
| Rate for Payer: HFN Commercial |
$40.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$35.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.40
|
| Rate for Payer: Preferred Network Access Commercial |
$40.48
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$28.60
|
| Rate for Payer: Quartz Medicare Advantage |
$26.40
|
| Rate for Payer: The Alliance Commercial |
$176.00
|
| Rate for Payer: WEA Trust Commercial |
$24.20
|
| Rate for Payer: WPS Commercial |
$32.59
|
|
|
SPLINT FUNCTIONAL POSITION R/L #A311-RL
|
Facility
|
OP
|
$486.00
|
|
| Hospital Charge Code |
2971300
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$136.08 |
| Max. Negotiated Rate |
$1,944.00 |
| Rate for Payer: Aetna Commercial |
$437.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.96
|
| Rate for Payer: Aetna Managed Medicare |
$136.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$315.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$243.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$233.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.58
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$447.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.97
|
| Rate for Payer: Health EOS Commercial |
$432.54
|
| Rate for Payer: HFN Commercial |
$447.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$364.50
|
| Rate for Payer: Multiplan Commercial |
$388.80
|
| Rate for Payer: NAPHCARE Commercial |
$291.60
|
| Rate for Payer: Preferred Network Access Commercial |
$447.12
|
| Rate for Payer: Quartz Beloit One Network |
$238.14
|
| Rate for Payer: Quartz Commercial |
$315.90
|
| Rate for Payer: Quartz Medicare Advantage |
$291.60
|
| Rate for Payer: The Alliance Commercial |
$1,944.00
|
| Rate for Payer: WEA Trust Commercial |
$267.30
|
| Rate for Payer: WPS Commercial |
$359.98
|
|
|
SPLINT FUNCTIONAL POSITION R/L #A311-RL
|
Facility
|
IP
|
$486.00
|
|
| Hospital Charge Code |
2971300
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$238.14 |
| Max. Negotiated Rate |
$447.12 |
| Rate for Payer: Aetna Commercial |
$437.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.58
|
| Rate for Payer: Cash Price |
$145.80
|
| Rate for Payer: Cigna Commercial |
$447.12
|
| Rate for Payer: Health EOS Commercial |
$432.54
|
| Rate for Payer: HFN Commercial |
$447.12
|
| Rate for Payer: Multiplan Commercial |
$388.80
|
| Rate for Payer: NAPHCARE Commercial |
$291.60
|
| Rate for Payer: Preferred Network Access Commercial |
$447.12
|
| Rate for Payer: Quartz Beloit One Network |
$238.14
|
| Rate for Payer: Quartz Commercial |
$291.60
|
| Rate for Payer: WEA Trust Commercial |
$267.30
|
| Rate for Payer: WPS Commercial |
$359.98
|
|
|
SPLINT FUNCTIONAL POSITION R/M #A311-RM
|
Facility
|
IP
|
$442.00
|
|
| Hospital Charge Code |
2971144
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$216.58 |
| Max. Negotiated Rate |
$406.64 |
| Rate for Payer: Aetna Commercial |
$397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$234.26
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cigna Commercial |
$406.64
|
| Rate for Payer: Health EOS Commercial |
$393.38
|
| Rate for Payer: HFN Commercial |
$406.64
|
| Rate for Payer: Multiplan Commercial |
$353.60
|
| Rate for Payer: NAPHCARE Commercial |
$265.20
|
| Rate for Payer: Preferred Network Access Commercial |
$406.64
|
| Rate for Payer: Quartz Beloit One Network |
$216.58
|
| Rate for Payer: Quartz Commercial |
$265.20
|
| Rate for Payer: WEA Trust Commercial |
$243.10
|
| Rate for Payer: WPS Commercial |
$327.39
|
|
